A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?
Document the infiltration.
Stop the infusion.
Elevate the arm.
Apply a warm compress.
The Correct Answer is B
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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Correct Answer is A
Explanation
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
Correct Answer is A
Explanation
A. The client has a decreased energy level.A decreased energy level can be a sign of hopelessness, as the client may feel a lack of motivation or purpose due to the terminal nature of the illness. This can manifest as fatigue, lethargy, or a general disinterest in activities.
B. The client requests a second opinion.Requesting a second opinion is generally a sign that the client is still actively engaged in their care and is seeking more information or alternative options. It indicates hope or a desire for different possibilities rather than hopelessness.
C. The client wants to talk about the diagnosis with the nursing staff.Wanting to talk about the diagnosis with the nursing staff suggests that the client is processing the information and seeking support. Open communication is a positive coping mechanism and not typically an indication of hopelessness.
D. The client makes funeral arrangements.Making funeral arrangements can be a practical and proactive approach to dealing with a terminal diagnosis. While it reflects an acceptance of the situation, it does not necessarily indicate hopelessness. Instead, it can show that the client is taking control of their end-of-life decisions.
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